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Thursday, January 30, 2014

You Can’t Fix Stupid, And Other Myths of Safety Management

We’ve all seen it – employees doing things that just boggle
our minds. Whether it’s knowingly violating procedures during high-risk
operations or even just missing what seem like extremely obvious signs that
something is wrong. Just in the last week we were at a maintenance shutdown
where an incident occurred in a confined space where the entrant ignored orders
from both his attendant and his own supervisor to leave the space. He
subsequently quickly exited the space when his supply of fresh air cut out
because his air hoses weren’t connected correctly and his escape bottles wasn’t
turned on properly.

It’s a common picture, right? We’d have safe organizations
if it weren’t for all these unreliable people! You just can’t fix stupid.

If there is a more ignorant phrase commonly used by safety
professionals we don’t know what it is. You
can’t fix stupid! We don’t blame people who say it, we’ve even said it from
time to time. But that statement represents a gross and dangerous
oversimplification of human behavior in complex systems. Here are a few reasons
why:

1. It’s not stupid!
Often when people “you can’t fix stupid” or similar phrases they are describing
behavior in hindsight with only a small part of the picture. The fact of the
matter is that often what we describe as “stupid” or even behaviors that we
call “errors” are often only that because of the results, not the actual
behaviors themselves. When people push boundaries and throw off the shackles of
conformity and it leads to success we call those people innovators and
entrepreneurs and we thank them for taking the initiative. When it doesn’t work
out we point out how we knew better and marvel at how stupid they were to think
it would work.

The point is that it’s not the behavior that’s stupid, it’s
our descriptions that are stupid and irrational. We often look at the same
behavior and call it something different depending on the result.

Consider this, if confined space entrant hadn’t run out of
air he likely would have gotten his job done quicker. What do you suppose would
have been the result?

2. You can fix it!
Whether you call it stupid or not, we do have influence over human performance.
Let’s just assume that the problem was that the person was extraordinarily dumb
– who decided that this person was the right person to do that job? At SCM our
mascot is a bulldog named Winifred. If we put Winifred in an Algebra class and
she doesn’t get a passing grade whose fault is that – Winifred’s for not
studying enough, or ours for putting the dog in a situation where she could not
possibly succeed?

Social science research suggests that behavior is decided by
a combination of three influences – individual factors (personality,
intelligence, etc.), social factors (peer influences, team interactions, etc.),
and environmental factors (tools and equipment, incentives, organizational
culture, etc.). Organizations have influence, directly or indirectly, over all
three areas. For example, in the confined space example above we can look at
all three areas and ask questions such as:

How were these employees selected
to do this high risk job and what training and experience do they have
(individual factors)?

Why weren’t the interactions
between the entrant, the attendant, and the supervisor more positive and how
can we ensure that those relationships create safety rather than reduce it,
such as through crew resource management training (social factors)?

What are the incentives in place
for the organization and why was the respiratory protection system so prone to
failure?

The bottom line here is that using phrases such as you can’t
fix stupid provide an excuse for safety managers to not look deeper in the system
to maximize human performance. Often when we resort to these sorts of phrases
to explain behavior it is a symptom of an organization that expects human
nature to conform to its system. That’s sort of like hoping that water will
start to flow uphill all by itself. If instead of putting the blame on people
(at any level in the organization) we look deeper at the individual, social,
and environmental influences and begin to create an organization that leverages
these influences to maximize human performance we may find that rather than
being the weakest link in our safety system, people actually become the most
reliable and important part of creating safety in our organizations.